International Journal for Equity in Health BioMed Central

Research Open Access Development and preliminary validation of the 'Caring for Country' questionnaire: measurement of an Indigenous Australian health determinant Christopher P Burgess*1, Helen L Berry2, Wendy Gunthorpe1 and Ross S Bailie1

Address: 1Menzies School of Health Research, Institute of Advanced Studies, Charles Darwin University, Darwin, NT, and 2National Centre for Epidemiology & Population Health, The Australian National University, Canberra, ACT, Australia Email: Christopher P Burgess* - [email protected]; Helen L Berry - [email protected]; Wendy Gunthorpe - [email protected]; Ross S Bailie - [email protected] * Corresponding author

Published: 18 December 2008 Received: 2 September 2008 Accepted: 18 December 2008 International Journal for Equity in Health 2008, 7:26 doi:10.1186/1475-9276-7-26 This article is available from: http://www.equityhealthj.com/content/7/1/26 © 2008 Burgess et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract Background: 'Caring for Country' is defined as Indigenous participation in interrelated activities with the objective of promoting ecological and human health. Ecological services on Indigenous-owned lands are belatedly attracting some institutional investment. However, the health outcomes associated with Indigenous participation in 'caring for country' activities have never been investigated. The aims of this study were to pilot and validate a questionnaire measuring caring for country as an Indigenous health determinant and to relate it to an external reference, obesity. Methods: Purposively sampled participants were 301 Indigenous adults aged 15 to 54 years, recruited during a cross-sectional program of preventive health checks in a remote Australian community. Questionnaire validation was undertaken with psychometric tests of internal consistency, reliability, exploratory factor analysis and confirmatory one-factor congeneric modelling. Accurate item weightings were derived from the model and used to create a single weighted composite score for caring for country. Multiple linear regression modelling was used to test associations between the caring for country score and body mass index adjusting for socio-demographic factors and health behaviours. Results: The questionnaire demonstrated adequate internal consistency, test-retest validity and proxy- respondent validity. Exploratory factor analysis of the 'caring for country' items produced a single factor solution that was confirmed via one-factor congeneric modelling. A significant and substantial association between greater participation in caring for country activities and lower body mass index was demonstrated. Adjusting for socio-demographic factors and health behaviours, an inter-quartile range rise in caring for country scores was associated with 6.1 Kg and 5.3 Kg less body weight for non-pregnant women and men respectively. Conclusion: This study indicates preliminary support for the validity of the caring for country concept and a questionnaire designed to measure it. This study also highlights the importance of investigating Indigenous-asserted health promotion activities. Further studies in similar populations are merited to test the generalisability of this questionnaire and to explore associations with other important Indigenous health outcomes.

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Background site for health [3]. This relationship is poorly understood, In Australia's (NT) more than 70% of unmeasured and receives only tacit recognition in Aus- the Indigenous population live on the 49% of the land- tralia's National Strategic Framework for Indigenous mass and 85% of the coastline that is Indigenous-owned health [16]. [1,2]. Colonial contact has largely displaced Indigenous peoples from their ancestral estates [3], relocating popula- Healthy Country Healthy People tions to remote area townships on Indigenous-owned Country is an Indigenous vernacular term encompassing lands [4]. This policy of centralisation, pursued in the last an interdependent relationship between Indigenous peo- decade with increasing vigour under the rubric of 'main- ples and their ancestral estates. streaming' [5,6], runs counter to evidence suggesting neg- ative health outcomes for these peoples [7,8]. In the "Country is multi-dimensional – it consists of people, ani- words of an Indigenous Australian: mals, plants, Dreamings; underground, earth, soils, min- erals and waters, air... People talk about country in the "Our identity as human beings remains tied to our land, same way that they would talk about a person: they speak to our cultural practices, our systems of authority and to country, sing to country, visit country, worry about social control, our intellectual traditions, our concepts of country, feel sorry for country, and long for country" [17]. spirituality, and to our systems of resource ownership and exchange. Destroy this relationship and you damage – Country is considered sentient [18], rewarding those who sometimes irrevocably – individual human beings and labour to maintain its mythic and physical integrity with their health" [9]. a bountiful harvest and bestowing physical, spiritual and social wellbeing [19]. Maintenance of health and well- Remote Indigenous townships are often described as cha- being requires hard work, sustained through mutual care otic and dysfunctional settings marked by social patholo- of kin, non-human affiliations and observance of ethical gies [10,11] and pervasive socio-economic disadvantages conduct described by the law or dreaming that is encoded [12]. Consistent with their extreme disadvantage, Indige- within country [17,19-21]. Failure to observe these obli- nous Australians' life expectancy is 17 years less than the gations may result in human sickness or ecological catas- Australian average with mortality rates for those aged 35– trophes [18,22]. 54 more than five times higher than the national average [10]. This also compares poorly with the life expectancy Urbanisation of remote Indigenous populations con- for Indigenous populations in New Zealand, Canada and strains opportunities to fulfil customary obligations to the United States [13]. For Indigenous Australians in the country. Although absence of landowners contributes to NT, a disproportionate burden of disease linked to inac- ecological degradation [23], contemporary forms of natu- tivity, malnutrition, and tobacco dependence underpins ral resource management have emerged to tackle environ- this wide health disparity [14]. Non-insulin dependent mental issues and maintain links with ancestral estates diabetes mellitus (NIDDM) and cardiovascular disease [24]. Indigenous ranger programs undertake a broad array account for 40% of excess Indigenous mortality and over of activities, including border protection, quarantine, and 21,800 preventable hospital admissions annually [10]. essential ecological services [3], that overlap with custom- Mainstream health promotion campaigns have been inef- ary obligations. fective in decreasing this burden of disease in such chal- lenging circumstances. Indigenous Australians living in homelands, where caring for country practices are common [25,26], appear to have Australia's peak health research body, the National Health better health outcomes compared to centralised popula- and Medical Research Council (NHMRC), recognises that tions [7,8,27,28]. Similarly, reinvigoration of a 'tradi- much previous health research "has not contributed in a tional lifestyle' delivers significant health improvements, significant or systematic way to improved health out- even for those with established NIDDM [29]. This is con- comes for Aboriginal and Torres Strait Islander popula- sistent with international examples of programs leverag- tions" [15]. Indigenous critics have demanded a shift in ing off extant cultural strengths to successfully combat research towards identifying 'what works', including (i) substance abuse and chronic diseases [30,31]. In the inter- improving the social determinants of health, (ii) identifi- national literature, however, there is a dearth of studies cation of cultural drivers of resilience and health gains and that explicitly engage, measure and validate Indigenous- (iii) the stipulation that solutions may arise from outside asserted health constructs, potentially overlooking signif- the health domain [15]. icant wellsprings of health promotion within Indigenous communities. There is a clear and urgent need for effective Indigenous health interventions. Indigenous Australians assert that The absence of any measure of Indigenous engagement in their relationship to ancestral land and sea is a prerequi- caring for country activities limits the potential to evaluate

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or inform policy decisions based on associations with Three participants did not complete the caring for country purported superior health outcomes [32]. questionnaire. Ten could not have weight and height recorded on the standardised equipment due to disability Aims of the present study (N = 1) and equipment delays in the aftermath of tropical We aimed to (i) test the validity of a questionnaire meas- cyclone Ingrid (N = 9). Nine failed to complete questions uring Indigenous participation in caring for country activ- on physical activity and diet. Five women were in the early ities and (ii) investigate the association between caring for stages of pregnancy and these participants were excluded country and an external health reference, body mass index from the final regression modelling of BMI. As there were (BMI), which is associated with the development of fewer than 5% missing data for any variable, and no miss- NIDDM and cardiovascular disease [33,34]. We expected ing data for most variables, we imputed missing data that higher levels of participation in caring for country using Full Information Maximum Likelihood estimation. activities would deliver more opportunities for exercise Imputed means and standard deviations were identical or and a more nutritious diet and would thus be associated near-identical to those derived from the dataset with miss- with a lower BMI. ing values; we used the imputed values for all further anal- yses. Methods This study was initiated by a traditional land-owner from Spending time on country, the seasonal burning of annual an Arnhem land community, who requested that grasses, gathering of food and medicinal resources, per- researchers investigate the links between participation in forming ceremonies, production of artworks and protect- natural resource management activities and human ing sacred areas are identifiable 'caring for country' health. Ethics approval was obtained in 2004 from activities [18,19,35]. Participants reported how often they Charles Darwin University (H04053) and the NT Depart- participated in these six activities over the preceding ment of Health and Community Services (04/35) which twelve months on a four point ordinal response format: 1 includes an Aboriginal ethics sub-committee approval = "Not much (none in the last year)"; 2 = "A little bit (a process. Approval was also granted from the Indigenous few days in the last year)"; 3 = "A fair bit (a few weeks in governed community health board and the Indigenous the last year)"; 4 = "Heaps (a few months in the last year)" governed outstation resource organisation. The study set- (Additional file 1). Two further questions investigated ting was a large remote Indigenous community in Arn- time spent on homelands: (i) "In the last year, where did hem Land. The township, a conglomerate of 11 language you spend most of your time living?" (the township groups established in 1957, is surrounded by 32 estab- name, homeland or other) and (ii) "How much time have lished homelands. This community has undergone a you lived in a homeland/outstation in the last five years?" rapid transition over 50 years, becoming largely sedentary (all the time, a few months each year, a few weeks each and reliant on income support. Within the population year, a few days each year or none). there is wide variation in caring for country participation. Follow-up and treatment were provided as clinically indi- Participants and procedures cated, including a feedback letter outlining an individu- Participants volunteering for the community preventive ally tailored strategy for good health. At the time of health check program were 301 Indigenous adults (177 feedback (a minimum of two weeks later) participants men, 124 women) aged 15 to 54 years (M = 30.96, Sx = completed the questionnaire a second time with the same 10.15), comprising 23.4% of the community population interviewer. Sixty-six participants (22% of the cohort) in this age range [4]. The cohort age structure differed repeated the questionnaire within 6 weeks (M = 30.7 days, slightly, but not significantly, from the census profile Sx = 7.99). (Pearson's Chi Square statistic: 10.04, p = .19) [4]. Of the participants, 298 (99%) completed an interviewer-admin- A senior Indigenous member of the community with well- istered caring for country questionnaire. The same inter- established community links across all language groups viewer administered the questionnaire on each occasion. and knowledge of all the participants also completed the Approximately one-third (N = 102) of participants came questionnaire for each respondent. This 'proxy respond- from 16 homeland communities and the remainder from ent' had not been involved in the health check program the township. We undertook purposive sampling to and had no knowledge of participant health outcomes or recruit participants with different levels of involvement in responses to the questionnaire. We compared the proxy's formal and customary caring for country activities. Partic- response with those of respondents', an acceptable and ipants were from homelands, township residences, work- validated method to verify health related behaviours in places (rangers and non-rangers) and public spaces remote Indigenous settings [36]. (outside the community store and community council buildings).

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Measures different language groups. The community male inform- Caring for country questionnaire development ants represented the Indigenous rangers, an executive The questionnaire was developed in four stages over a from the outstation resource centre and a member of the two-year period of collaboration with an Indigenous com- community health board. The community female inform- munity in Arnhem Land. ant was an employee of the women's centre. All commu- nity informants were fluent in English and several local Stage 1: Scoping Study, Literature review, consultation and Indigenous languages, identified with landowning groups participant observation and had in their lifetimes lived for extensive periods of Several databases covering a range of disciplines were time in remote homelands. The final Indigenous male searched for material on Indigenous caring for country informant, aged in his fourth decade, was based in Dar- and health. These included: APAIS, MEDLINE, PubMed, win and had over ten years of experience facilitating for- CINAHL, ATSI-health, Anthropological index online, ISI. mal Indigenous natural resource management programs Ethnographies, textbooks and conference proceedings in widespread locations across the NT. covering Indigenous themes were included and helped to identify leading authors in this field, who were contacted All Indigenous informants readily understood the pur- by phone or email. Six field trips of up to 2 weeks duration pose of the questionnaire and did not volunteer any addi- enabled the first author to establish relationships with key tional items. The item regarding energy arising from Indigenous and non-Indigenous informants and under- caring for country was considered to be real and impor- take participant observation of both formal 'ranger' pro- tant but too difficult to include in the linguistically diverse grams and informal, customary management practices. research setting and was excluded at this stage. Item spe- While no previously validated measures of caring for cific cues and quantification cues were considered intelli- country were identified, five potential questionnaire items gible and appropriate. The need for an interviewer were identified from extant literature: time on country, administered questionnaire was highlighted. Three Indig- burning, using country, protecting country and ceremony. enous informants felt that the division of ceremonial (Povinelli, 1993, Rose, 1992, p106–7). activity between funeral rites and other ceremonies was an artificial one and these two items were combined into a Stage 2: Content Validity assessment with non-Indigenous informants single ceremony category. Four male non-Indigenous informants were identified during the scoping study. All had lived and worked in Stage 4: Construct validity assessment through key informant remote Indigenous communities for over 20 years. Three interview of these informants were still resident in remote commu- Finally, a semi-structured interview with an Indigenous nities at the time of consultation. One was resident in Dar- male from the community was undertaken based on the win but maintained active involvement in Indigenous caring for country questionnaire developed in the previ- ranger programs. Three of the non-Indigenous informants ous three stages. This key informant, aged in his fifth dec- had a direct association with the research community, and ade, had well developed links across all language groups the fourth had no direct association with the community through his employment as an Aboriginal mental health but was resident in a remote coastal Aboriginal commu- worker. He had spent extensive periods in both home- nity. lands and in employment with non-Indigenous agencies in the township setting. This discussion was recorded on A sixth scale item, production of artefacts, was suggested a digital voice recorder, predominantly in English, at the and several plain language cues for each item were volun- choice of the interviewee, but supplemented with Indige- teered, corresponding to colloquial expressions in the nous language to convey key concepts. Translations, community. An additional item concerning the reciprocal where necessary, were supplied by the principal informant nature of caring for country, specifically the energy and and verified [37]. vitality that arose from participation. (Thomson, 1975), was suggested by one informant. Subdivision of ceremo- In this community, caring for country activities were qual- nial activity between funeral rites and other ceremonies itatively associated with an holistic health construct, an- was also suggested ngurrunga-wana, a state of vitality of mind, body and soul, roughly translated as "he-soul-big" [37]. This construct Stage 3: Content Validity assessment with Indigenous informants forms the a priori hypothesis for measure development. Five Indigenous informants, four from the research com- We expected all scale items would load on a single latent munity and one from outside the community assessed the factor, an-ngurrunga-wana. content validity of the questionnaire. The four commu- nity informants (3 male and one female) were a purposive Further construct validity assessment of the items within sample. All aged in their fifth decade, they were employ- the questionnaire was also guided by Reid's [38] 'Body, ees of disparate community agencies. They were from four Land and Spirit' domains – an interpretive framework of

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Yolngu health beliefs in north east Arnhem land. Time on diometer, following accepted techniques [43]. Partici- country, using country and burning are linked in practice pants wore light clothing and had bare feet. BMI was [39], and involve direct interaction with specific land- derived by dividing weight in kilograms by the square of scapes. These three items may pertain to the dimension of the person's height in metres. land. Ceremony and protecting country are linked to spir- itual beliefs and practices to maintain the spiritual integ- Statistical methods rity of landscapes [22] and may pertain to the dimension Descriptive statistics were computed for the cohort. Item of spirit. The production of artefacts: carvings, paintings, endorsement, inter-item correlations, quadratic weighted weavings and other decorative or utility items are concrete kappa scores for test-retest and proxy response reliability expressions of specific landscapes or ancestral knowledge were calculated. Exploratory factor analysis was appropri- [35,40]. Artefacts may thus pertain to body or the 'mate- ate for a preliminary investigation of the factor structure rial embodiment' of land and spirit domains. (Additional underlying the items. The dataset was appropriate for file 2) exploratory factor analysis [44]: the questionnaire items were theoretically related; the study was designed for fac- The interviewer also collected data on primary place of tor analysis; the dataset was factorable (multiple inter- residence, education, income, diet, physical activity, alco- item correlations > .3); the sample size was adequate and; hol consumption and smoking status. While we expected sampling statistics were acceptable (Kaiser-Meyer-Olkin that participants engaging in higher levels of caring for statistic = .84, Bartlett's test of sphericity p < .0001). Max- country would come from homelands [25,26], we wished imum likelihood factoring with oblimin rotation were to control for residence in our analysis because (i) caring used to allow for skewed data and a correlated solution for country participants could come from the township; (should the solution contain more than one factor) (ii) not all homelands residents care for country and (iii) respectively. Evaluation criteria were consistency with the- homelands residents may have differing dietary and phys- ory, factor loadings exceeding .45 and eigenvalues > 1.0. ical activity factors, based on their isolation, which could potentially confound caring for country in predicting One-factor congeneric modelling (see Berry [45]), a sub- BMI. set of structural equations modelling, was used to (i) test and refine the exploratory factor solution and (ii) generate Socio-demographic factors a set of accurate item weightings for the creation of a Income was divided into three ordinal categories: 1 = weighted composite scale (Range = .76–3.06, M = 1.93, Sx unemployment benefits (lowest income); 2 = Abstudy = .67). The model was fitted using an asymptotic distribu- (Aboriginal education support payments), Community tion free algorithm to accommodate non-normal distribu- Development Employment Program, carer allowance, tions in the data. Model fit was assessed by a holistic child support, receiving payments for artefact production appraisal of the χ2 statistic, critical ratios, and a selection (middle income); 3 = salaried positions (highest income). of goodness of fit indices (absolute fit, incremental fit and This last category was rare, including only 1.3% of parsimony indices). respondents. Educational attainment was categorised as: 1: no formal education; 2: primary education; 3: lower Recent research has suggested that breadth of community secondary; 4: year ten; 5: year twelve; 6: post school qual- participation across a range of important types of partici- ification. Higher levels of education have been asserted to pation is more strongly linked to wellbeing than is the deliver better health outcomes in Indigenous populations mean amount of participation, or very high levels of any [41]. particular type of participation [45]. We investigated whether this may be true of any association between par- Diet data were collected with standardised visual cues ticipating in caring for country and health. In our regres- depicting commonly available foodstuffs that participants sion analyses, we compared a single weighted composite reported consuming: never; sometimes; most days; every score for caring for country, derived from the one-factor day. Physical activity was assessed by a question adapted model, with an index of total number of types of caring from the Australian longitudinal study on women's for country in which respondents participated. The index health: "How many times a week do you exercise enough was created by dichotomising item scores by mean split, to get short of breath or huff and puff?" [42]. This was assigning a value of 0 (non-participator – below the accompanied by visual cues depicting sporting activity, mean) and 1 (participator – at or above the mean), and hunting, digging and ceremonial dancing. Participants summing these scores. This generated a seven-point index reported; none; one or two times; three or four times; (Range = 0–6, M = 2.73, Sx = 2.22). An un-weighted com- more than four times. Smoking status was assessed by ask- posite scale and the index demonstrated satisfactory inter- ing: "Do you smoke tobacco?" (yes/no). nal coherence (Cronbach alpha scores = .88 and .85 respectively). Cronbach alpha scores cannot be derived Weight was recorded on digital scales to the nearest 100 g for weighted composites. and height to the nearest centimetre, using a mounted sta- Page 5 of 14 (page number not for citation purposes) International Journal for Equity in Health 2008, 7:26 http://www.equityhealthj.com/content/7/1/26

Multivariate logistic and ordinal logistic regression analy- strong. Item-total correlations of .5 were exceeded for all ses were performed to evaluate whether caring for country items and sequential removal of items had negligible predicted obesity-related health behaviours, controlling effect on the Cronbach's alpha coefficient for the for socio-demographic factors and other health behav- unweighted composite score (Table 2). iours. Multiple hierarchical regression models were used to test the relationship between caring for country and Spearman correlations among the responses to time on BMI. The models included variables tapping social deter- country and responses to 'time spent on homelands' (-.77, minants, residence, health behaviours and caring for p < .001) and 'primary place of residence in the last year' country. Analyses were performed using Stata [46], SPSS (.75, p < .001) indicated satisfactory concurrent validity. [47], and AMOS (structural equation modelling) [48]. All test-retest quadratic weighted kappa scores exceeded .5, indicating satisfactory reliability. Proxy respondent Results quadratic weighted kappa scores were lower with only the Weight total score and time on country item exceeding .5. How- BMI was calculated for 301 participants (Range = 12.6– ever, for both individual and proxy respondent comple- 42.3, M = 22.91, Sx = 5.58). On average, this was a lean tion, observed agreement always significantly exceeded population with mean BMI decreasing from 23.57 in expected agreement (p < .001) (Table 2). those with the lowest level of participation in caring for country activities to 22.01 for those with the greatest level Exploratory factor analysis of the caring for country items of participation (Table 1). Men were slightly leaner (BMI generated a one-factor solution accounting for 63.6% of M = 22.47, Sx = 4.92) than were non-pregnant women variance in an-ngurrnga-wana, with all factor loadings (BMI M = 23.67, Sx = 6.43). exceeding the criterion of .45 (Table 2). As this was a sin- gle factor solution, rotation was not appropriate. The ini- Caring for country tial one-factor congeneric model (OFCM) did not fit the Quantification category endorsement of the caring for data well. As there were no non-significant variables or country items varied from 3.7% to 66.4%. Item response loadings, no items or pathways were deleted and the mod- skew was uncommon except for the artefact production ification indices were inspected. Two pairs of error terms, item. Pearson Product Moment Correlation coefficients concurring with Reid's land, body and spirit domains, among questionnaire items were positive and moderate to were covaried one at a time. The model was comprehen-

Table 1: Cohort characteristics by low, medium and high caring for country scores.

Low (score: 6–12) Medium (score: 13–18) High (score: 19–24)

Mean Sx Mean Sx Mean Sx

Number of participants 122 N/a 105 N/a 74 N/a % Male 61% N/a 58% N/a 57% N/a Age in years 29.27 10.50 30.84^ 10.05 33.79 9.21 Socio-demographics % Resident in homelands 2.5%^^^ N/a 38.1%^^^ N/a 79.7% N/a Mean income level 1 1.50^^^ .52 1.90 .38 1.92 .27 Mean education level 2 3.03 1.05 2.89 .89 2.67 .83 Health behaviours % Smoker 70% N/a 75% N/a 74% N/a % Drinks alcohol 30.3% N/a 37%^ N/a 20.3% N/a Physical activity 3 2.84^ .92 3.08^^^ .84 3.5 .61 Takeaway 4 2.26 *** .66 1.97 .57 1.91 .52 Store Fruit 4 2.40 .74 2.51* .78 2.25 .54 Store Vegetable 4 2.37 .71 2.57** .77 2.25 .58 Bush meat 4 3.1^^^ .76 3.52^^^ .74 3.86 .37 Bush fruit and vegetable 4 2.71^^^ .92 3.27^^ .86 3.61 .64 Health outcome Body Mass Index 23.57 6.30 22.86 5.11 22.01 4.86

Notes: 1: 1 = lowest income, 2 = medium income, 3 = highest income 2: 1 = no formal education, 2 = primary school, 3 = lower secondary, 4 = year ten, 5 = year twelve, 6 = post school qualification 3: 1 = none, 2 = one or two times a week, 3 = three or four time a week, 4 = more than four times a week 4: 1 = never, 2 = sometimes, 3 = most days, 4 = every day *p < .05, **p < .01, ***p < .001: score is significantly higher than that of the next group ^p < .05, ^^p < .01, ^^^p < .001: score is significantly lower than that of the next group

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Table 2: Caring for country questionnaire internal consistency, item factor loads and reliability calculations.

Questionnaire Item-total Item-rest Alpha when item Factor loading OFCM factor κ Test-retest κ Proxy item correlation correlation removed score weight respondent

Time on country .84 .75 .85 .87 .14 .88*** .57*** Burning .86 .78 .84 .86 .27 .76*** .47*** Using country .86 .79 .85 .89 .19 .81*** .48*** Protecting .83 .75 .85 .73 .11 .64*** .37*** country Ceremony .73 .60 .88 .58 .01 .52*** .34*** Artefact .65 .50 .89 .50 .05 .90*** .47*** production Summed raw .89*** .59*** score (Range: 6–24)

Note: *p < .05, **p < .01, ***p < .001: observed agreement is significantly more than expected agreement sively re-evaluated after each covariance. The final model weighted composite scale score were tested using logistic fitted the data well and achieved the lowest value for the regression (smoking and alcohol) or ordinal logistic parsimony indices, indicating the model had not been regression (diet and physical activity) predicting heath over-fitted (Figure 1 and Table 3). Questionnaire items behaviours. Socio-demographic variables (age, gender, were multiplied by the factor weights obtained from the income, education and residence) were included in the OFCM and then summed to generate weighted caring for first step and other health behaviours (smoking, alcohol, country scale scores. takeaway, store foods, physical activity and caring for country) in the second step. Bush food consumption was All caring for country items were negatively correlated excluded from the modelling because this was part of the with BMI such that mean BMI decreased as mean caring construct definition of caring for country. Non-significant for country scores increased (Table 1). Four items pro- predictors of each health behaviour were eliminated at duced significant zero-order correlations and five items each step, one at a time, starting with the variable with significant partial correlations, controlling for age, gender smallest beta-value. The model was comprehensively re- and residence (Table 4). evaluated after each deletion until only significant predic- tors remained. Zero-order and partial correlation between each item and BMI were larger and stronger for the weighted scale than Age and alcohol significantly and independently pre- for the index; the weighted scale score was used in all fur- dicted smoking, with alcohol consumption associated ther analyses. with a threefold likelihood of smoking (Table 5). Being male and smoking predicted alcohol use with smoking Caring for country and health behaviours associated with an almost fourfold likelihood of drinking. Multivariate relationships between social determinants, Being male, greater education, living in a homeland and residence, health behaviours and the caring for country caring for country independently predicted greater physi- cal activity with caring for country demonstrating the Table 3: Fit indices for one-factor congeneric model – unfitted and fitted models. strongest independent association. Being female, older age, greater education, homelands residence and caring Fit Index Acceptable values Unfitted model Fitted model for country each independently predicted less frequent consumption of takeaway food, with residence and caring CMIN p > .05 56.69 16.82* for country displaying around a two-fold reduction. Being CMIN/DF 1 to 2 6.30 2.40 female and, in particular, store vegetable consumption, RMSEA < .08 .13 .07* RMR < .05 .11 .046* were associated with more frequent consumption of store GFI > .90 .96* .99* fruit, while age and greater physical activity independently AGFI > .90 .91* .97* predicted less frequent consumption. Greater income and TLI > .90 .83 .95* especially consumption of store fruit were independently CFI > .95 .90 .98* associated with more frequent consumption of store veg- NFI > .95 .88 .97* etables. Being female, caring for country, alcohol use, AIC Lowest 80.69 44.82* higher education levels, and greater physical activity were CAIC Lowest 137.17 110.72* independently associated with more frequent bush meat Note: * = acceptable value consumption while consumption of takeaway was associ-

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FittedFigure one 1 factor congeneric model and standardised estimates of an-ngurrngna-wana Fitted one factor congeneric model and standardised estimates of an-ngurrngna-wana.

Table 4: Pearson Product Moment Correlation coefficients among caring for country questionnaire items, and zero-order and partial correlations with body mass index.

23456Body mass index

Zero-order Partial1

1. Time on Country .80*** .77*** .58*** .43*** .39*** -.12* -.12* 2. Using Country -- .76*** .64*** .48*** .40*** -.18** -.20** 3. Burning -- .60*** .46*** .47*** -.15** -.19** 4. Protecting country -- .72*** .43*** -.15** -.19** 5. Ceremony -- .39*** -.04 -.05 6. Artefact production -- -.06 -.12* Weighted scale score -.17** -.22*** Index -.12* -.15**

Notes: 1. Controlling for gender, age, residence and shared associations with the other caring for country items. * p < .05, ** p < .01, ***p < .001.

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Table 5: Logistic and ordinal logistic regression estimates for the prediction of health behaviours by socio-demographic factors, residence, health behaviours and weighted composite caring for country score.

Odds ratio S E 95% CI Pseudo R2

Smoker .12*** Age 1.07*** .02 1.04 – 1.10 Alcohol use 3.36* 1.27 1.61 – 7.04

Alcohol use .08*** Female gender .29*** .08 .17 – .52 Smoker 2.52** .80 1.35 – 4.73

Physical activity .08*** Female gender .55** .12 .35 – .85 Education level 1.55*** .19 1.22 – 1.97 Homeland resident 2.26* .76 1.17 – 4.38 Caring for country 2.31*** .55 1.45 – 3.68

Takeaway consumption .06*** Age .97* .01 .95 – .99 Female gender .53* .13 .32 – .87 Education level .72* .10 .55 – .94 Homeland resident .45* .18 .21 – .99 Caring for country .52* .14 .30 – .90

Store fruit consumption .23*** Age .97* .01 .94 – .99 Female gender 1.80* .31 1.07 – 3.03 Store vegetables 14.29*** 3.56 8.78 – 23.25 Physical activity .70* .11 .52 – .95

Store vegetable consumption .22*** Income level 1.79* .49 1.05 – 3.05 Store fruit consumption 16.29*** 3.87 10.23 – 25.95

Bush meat consumption .15*** Female gender 2.31** .62 1.37 – 3.90 Homeland resident 4.71*** 1.96 2.09 – 10.63 Education level 1.36* .18 1.04 – 1.76 Physical activity 1.38* .22 1.02 – 1.88 Takeaway consumption .65* .14 .43 – .99 Alcohol use 1.78* .50 1.01 – 3.06 Caring for country 2.15** .52 1.34 – 3.45

Bush fruit & vegetable consumption .15*** Female gender 4.95*** 1.31 2.95 – 8.30 Homeland resident 5.65*** 2.10 2.73 – 11.71 Education level 1.47** .19 1.14 – 1.88 Alcohol use 2.21** .60 1.31 – 3.75 Caring for country 2.36*** .58 1.45 – 3.81

Note: * p < .05, ** p < .01, ***p < .001. ated with less frequent bush meat consumption. Home- As gender was a significant independent predictor of six of lands residence, being female, higher education level, the eight health behaviours, we tested interaction terms alcohol use and caring for country were independently between sex and caring for country, diet, substance use associated with more frequent bush fruit and vegetable and physical activity predicting BMI. As most of these consumption. Being a homelands resident was the most terms were strongly and significantly associated with BMI, significant predictor for greater frequency of bush food we analysed data for women and men separately. consumption.

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Caring for country and BMI benefits of homelands residence [8] and reinvigoration of Hierarchical linear regression modelling was used to test a 'traditional lifestyle' [29]. caring for country as a predictor of BMI (Table 6). Non- significant predictors were deleted, one by one, starting Consistent with recent findings in a comparable remote with the predictor with the lowest beta value, until only Indigenous community [49], mean BMI levels in this significant predictors were retained in the models. study indicate a lean population compared to Australia's national prevalence of 51% of overweight and obesity in In the first step, for both men and non-pregnant women, adults (defined as BMI ≥ 25) [50]. However, this does not only age made a significant independent contribution to imply less risk for development of diabetes and cardiovas- explaining BMI scores, accounting for 4% of the variance. cular disease, because these diseases occur at lower BMI In the final model for men, in order of importance, age, levels among Indigenous people, with risk increasing caring for country, and smoking were independently incrementally with rising BMI [33,34,49,51]. related to BMI, accounting for 9% of variance in men's BMI. For non-pregnant women, in order of importance, Male and female participants reported different health age and caring for country were independently related to behaviours, but similar associations with BMI. For men, BMI, accounting for 7% of variance in women's BMI. health behaviours were associated with BMI as hypothe- sised. Unexpectedly, given the similar prevalence of smok- Given mean heights of 1.60 m and 1.71 m for non-preg- ing for men and non-pregnant women, for women, nant women and men respectively, and a caring for coun- smoking did not demonstrate an independent relation- try weighted scale inter-quartile range of 1.14 and 1.23, ship with BMI. This may be due to fewer numbers of ciga- non-pregnant women who participated in caring for rettes smoked each day (not measured in this study) but country activities weighed, on average, 6.1 Kg (95% CI = this requires examination in further work. 1.1–11.2) less than non-participants and men 5.3 Kg (95% CI = 1.6–9) less. We investigated the reliability and validity of the ques- tionnaire in a challenging setting and it demonstrated sat- Discussion isfactory internal consistency. Reliability was We have demonstrated the preliminary validity of an demonstrated through acceptable test-retest and proxy inductively derived questionnaire measuring Indigenous respondent agreement [52]. Content validity was participation in caring for country activities and described achieved through a two-year collaboration with key Indig- a significant and substantial inverse association with BMI. enous and non-Indigenous informants from within the We found that participation in caring for country activities study setting. We could not pit our measure against an was significantly associated with greater physical activity, existing gold standard measure of Indigenous Caring for less frequent consumption of takeaway and more fre- Country because no such measure is available; indeed, a quent consumption of bush foods – health behaviours strength of our research is the development of such a that contribute to less obesity [29]. These findings are con- measure. In demonstrating moderate agreement among sistent with previous research documenting the health additional items assessing time on country, it shows con-

Table 6: Multivariate regression estimates for the prediction of BMI by socio-demographic factors, residence, health behaviours and weighted composite caring for country score for men and non-pregnant women.

BS E B 95% CI β R2

Men (N = 177) Step 1: Socio-demographics .04** Age .10 .04 .03 – .17 .21** Step 2: Health behaviours .09*** Age .13 .04 .06 – .21 .27** Smoker -1.73 .85 -3.41 – -.07 -.16* Caring for country -1.50 .52 -2.53 – -.47 -.21**

Non-pregnant women (N = 119) Step 1: Socio-demographics .04* Age .12 .06 .01 – .23 .20* Step 2: Health behaviours .07** Age .13 .06 .04 – .26 .25** Caring for country -2.10 .87 -3.83 – -.37 -.22*

Note: * p < .05, ** p < .01, ***p < .001.

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current validity. Construct validity was demonstrated by impede weight gain. Given the strength of our findings, a (i) exploratory factor analysis indicating a one-factor solu- longitudinal study is merited. tion, consistent with the local Indigenous construct of an- ngurrunga-wana, (ii) a fitted one factor congeneric model, Second, there may be a selection bias in this study. Volun- also consistent with our hypothesis and with the Yolngu teers for a preventive health check may not be representa- health tri-partite of land, body and spirit, (iii) higher car- tive of the population burden of morbidity as they tend to ing for country scores among expected groups, such as be more health-conscious [54]. Additionally, those with homelands residents, and (iv) the significant and substan- established disease and receiving treatment may be less tial association of the scale score, in the expected direc- likely to participate. However, we purposively sampled tions, with key health behaviours and with our external just under a quarter of the eligible population, aged 15 – reference, obesity. 54 years. This sample did not differ significantly from the census age profile [4]. We also achieved a high question- The weighted scale score achieved stronger and more sub- naire response rate. Further, if those with established dis- stantial associations with BMI than did the index, indicat- ease or poor health were excluded, the results of this study ing that total quantity of participation is more important would constitute (i) a conservative estimate of the health in achieving a lower BMI than is breadth of participation. benefits of caring for country and (ii) increased probabil- This is consistent with the proposition that greater physi- ity that caring for country is linked to better health cal activity and a healthier diet, associated with caring for because those physically unable to care for country were country practices, would deliver a more favourable meta- excluded from this study. Finally, while a stratified ran- bolic state [29]. However, breadth of participation in car- dom sample may have been a desirable alternative sam- ing for country activities may be important in other pling strategy, this was impractical in the research setting socially mediated outcomes, as it is for mental health due to (i) high population mobility, (ii) the absence of an [45]. This requires further research. accurate community population list and (iii) the need to obtain a much larger sample and collect data for a wider We observed a strong association in this study between range of co-morbidities. residence in homelands and greater participation in car- ing for country. Residence also demonstrated significant Third, several of our measures were crude, reliant on self- independent associations with less frequent takeaway report and administered in English. Other measures were consumption, more frequent physical activity and more Eurocentric; for example, income did not include all frequent consumption of bush foods – behaviours that forms of subsistence production [25], and education did would be expected to contribute to a lower BMI [29,53]. not include traditional knowledge, which is equally Unexpectedly, however, residence was not a significant important in Indigenous communities [41]. While some independent predictor of BMI in the final regression self-reported health behaviours, such as dietary assess- model. This may indicate that participation in caring for ment, are notoriously inaccurate [55], we could not country activities mediates the relationship between resi- undertake objective measurement of all behaviours sub- dence and weight, suggesting that homeland residence is ject to the questionnaire items because participants were associated with lower weight because it engenders a health- widely dispersed and may have found it intrusive. We ier lifestyle. If so, this highlights the value of adequately expect this issue to arise for other research teams. To resourced programs that support Indigenous ranger address it, we have tested the reproducibility of self- groups (predominantly based in township locations) and reported caring for country activities through test-retest, residents in homelands, both of whom maintain caring triangulation with proxy respondent rating and sophisti- for country practices [23,24]. cated statistical modelling. Our methods are consistent with and extend previous research in remote Indigenous Limitations of this study communities that have used respondent rating to investi- We present four main limitations in this study. Firstly, as gate health behaviours [36]. Unfortunately, translation ours is a cross-sectional study, we are unable to determine was not possible due to the lack of qualified interpreters the causal direction between caring for country and BMI. for the eleven language groups. Nevertheless, our ques- However, this was not an aim of our study, which was, tions, piloted and refined with Indigenous health workers instead, to validate a measure of an Indigenous asserted in preparation for the study, were considered comprehen- health promotion activity and to relate it to an external sible and in a suitable format for this population. Plausi- reference, obesity. Consistent with a longitudinal study of ble associations between caring for country and health homelands residents in central Australia that observed sig- behaviours and obesity support this assessment. nificantly lower BMI over time, compared to township residents [8], our findings indicate that caring for country Finally, this scale was developed in a single remote Indig- is associated with health behaviours that are likely to enous community in Arnhem Land fifty years after the

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founding of the township. Other Indigenous communi- ment could have substantial health and cultural benefits ties with differing linguistic and cultural heritage, or even for Australia's most disadvantaged and dispossessed peo- this community in coming years, may define caring for ples. We emphasise the importance of engaging with country differently. However, much of the ethnographic Indigenous-asserted health promotion activities that theory underpinning our scale development came from could well make a contribution – inexpensively and other NT Indigenous communities with longer periods respectfully – to tackling seemingly intractable disadvan- cultural disruption [18,19]. More broadly, the cultural tage in remote Australia. expression, protection of the environment, healthier life- styles and participation in society encompassed by the Competing interests questionnaire items resonate with a Maori model of The authors declare that they have no competing interests. health promotion [56] and the health concepts outlined in the Geneva convention on the health and survival of Authors' contributions Indigenous peoples [57]. CPB conceived the study, undertook the data collection, statistical analysis and had primary responsibility for We argue that the caring for country activities would be drafting the manuscript. HB assisted with the study relevant to other remote Indigenous populations on their design, supervised the statistical analysis, presentation, own land in remote areas of Australia. Indigenous Austral- interpretation of results and critically reviewed the manu- ians possess great diversity in linguistic and cultural tradi- script. WG participated in the design of the study and tions and the questionnaire requires further testing in reviewed the manuscript. RB provided advice on data different settings. However, the study cohort was generally analysis and interpretation and helped draft the manu- representative of remote NT Indigenous peoples in terms script. All authors read and approved the final manu- of language diversity, residence patterns and a varied par- script. ticipation in customary and contemporary caring for country activities. Further studies are required in similar Additional material communities to test the generalisability of this question- naire and investigate associations between caring for country and other health outcomes. Additional file 1 Appendix 1. Caring for Country questionnaire. Click here for file Conclusion [http://www.biomedcentral.com/content/supplementary/1475- We have used a theory-based cross-sectional study to sys- 9276-7-26-S1.doc] tematically validate an Indigenous-specific questionnaire for participation in caring for country activities and its Additional file 2 relationship to a health outcome and health behaviours Appendix 2. Theoretical dimensions of the Caring for Country question- relevant to premature Indigenous morbidity and mortal- naire [38]. ity. The questionnaire performed well in this cohort across Click here for file [http://www.biomedcentral.com/content/supplementary/1475- all tests. Further work investigating associations with a 9276-7-26-S2.doc] broader array of health outcomes is ongoing.

Formal Indigenous caring for country programs have received some support to date [58,59], but are largely reli- Acknowledgements ant on income support payments [23]. We believe that a This study was supported by NHMRC grants #333421 & #320860, Pfizer substantial expansion of investment in Indigenous man- CVL. This study did not involve the use of any Pfizer products nor did Pfizer agement of their lands to perform essential environmen- receive any commercial benefit from this study. Paul Burgess was supported tal services would reap significant health benefits in by a PhD scholarship, initially from the Centre for Remote Health and, sub- addition to known environmental benefits [23,60]. This sequently, NHMRC public health scholarship #333416. Ross Bailie's work could be relatively inexpensive, low-risk and easy to is supported by a NHMRC Senior Research Fellowship #283303. This project has been endorsed as an in-kind project of the Cooperative implement, yet would deliver ecological gains [61], eco- Research Centre for Aboriginal Health, a collaborative partnership funded nomic development, for example through participation in by the CRC Programme of the Commonwealth Department of Innovation, emerging carbon trading markets [62] and, potentially, Industry, Science and Research. health gains via physical, social and cultural pathways [32]. References 1. Taylor J: Indigenous economic futures in the Northern Territory: The demo- graphic and socioeconomic background CAEPR, ANU, Canberra; 2003. Our study provides empirical epidemiological support for 2. SCRGSP: Overcoming Indigenous Disadvantage: Key Indica- long-standing Indigenous demands for institutional tors 2007. Canberra: Steering Committee for the Review of Gov- investment in managing their country [24]: such invest- ernment Service Provision, Productivity Commission; 2007.

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